If Ratio 3 is more
than Benchmark Ratio (Ratio 1), a refund or credit to premium is not required.

If Ratio 3 is less
than the Benchmark Ratio, then proceed.

12.

Adjusted Incurred Claims =

[Total Earned Premiums (line 3,
col. a) - Refunds Since Inception

(line 6)] x Ratio 3 (line 11)

13.

Refund = Total Earned Premiums
(line 3, col. a) -

Refunds Since Inception (line 6) -

Adjusted Incurred Claims (line 12)

-----------------------------------------

Benchmark Ratio (Ratio 1)

If the amount on
line 13 is less than .005 times the annualized premium in force as of December
31 of the reporting year, then no refund is made. Otherwise, the amount on line
13 is to be refunded or credited, and a description of the refund and/or credit
against premiums to be used must be attached to this form.